Ultrasound, electromyography, and balloon guidance for injecting botulinum toxin for cricopharyngeal achalasia: A case report

Abstract

Introduction: Botulinum toxin (BTX) injection is a widely used treatment option for dysphagia associated with cricopharyngeal (CP) muscle achalasia, but uniform standards and protocols for administration techniques and injection sites are still lacking. This case study suggests that a unique administration technique involving a combination of ultrasound, electromyography, and balloon guidance for injecting the CP muscle can reduce inadvertent migration of BTX to non-injected tissues and increase the effectiveness and safety of BTX treatment.

Patient concerns: We describe the case of a 74-year-old man who could not swallow food or saliva for 8 months.

Diagnosis: The patient showed signs of true bulbar paralysis, including dizziness, hoarseness, and dysphagia. The fiberoptic endoscopic evaluation of swallowing showed massive mucilage secretion and residual materials in the postcricoid region and aspiration when swallowing 1 ml of yogurt. The video fluoroscopic swallowing study showed profoundly limited epiglottic folding and CP muscle non-relaxation, despite several unsuccessful swallow attempts.

Interventions: To manage insufficient relaxation opening of the CP muscle, BTX injection was performed using ultrasound, electromyography, and balloon catheter guidance. The narrow CP muscle situated above the balloon was identified as the target of injection by ultrasound.

Outcomes: The patient was able to eat a soft diet. The follow-up fibrotic endoscopic swallowing study demonstrated a reduction in the amount of pharyngeal residue. The video fluoroscopic swallowing study showed that CP muscle relaxation was significantly enhanced and no penetration was shown.

Conclusion: The unique administration technique with triple guidance holds several advantages, suggesting that it may be a promising treatment for CP muscle achalasia.

Figure 1

(A) MR diffusion weighted imaging suggests the acute medullary infarction in left-side cerebellar (white arrow) and medullary (white sharp triangle). (B) Sagittal plane CT of chest showed multiple inflammatory patchy shadows in both lungs.

Figure 2

(A) Before injection, FEES revealed penetration/aspiration and pooling in the postcricoid region (red arrow). (B) After injection, FEES demonstrated the reduction in amount of pharyngeal residue. (C) Before injection, VFSS showed the case of a profoundly decreased epiglottic folding and CP muscle non-relaxation despite several invalid swallow attempts. (D) After injection, VFSS revealed a much improved CP muscle opening, decreased amount of residue, and no penetration and aspiration.

Figure 3

(A) An ultrasound showed that the dilated balloon of a Foley catheter was blocked and situated below the CP muscle before injection. White arrow: the CP muscle. White sharp triangle: The left common carotid artery. Red arrow: The inflated balloon below the CP muscle. Red sharp triangle: The thyroid. Green arrow: The windpipe. (B) Ultrasound-guided injection to the CP muscle and sagittal view for in-plane approach. White arrow: The CP muscle. White sharp triangle: The advancement of the needle (diameter 0.51 mm, length 60 mm). Red arrow: The thyroid cartilage. Red sharp triangle: The thyroid.